HospitalInspections.org

Based on observations, record reviews and interviews, the hospital failed to ensure patients received care in a safe setting. This deficient practice was evidenced by:

1.) the toilets in the patients' bathrooms having a gap between the base of the toilet and the wall creating a ligature point and having toilet seats that could be raised, creating a ligature point at the hinge where there was an opening.; and
2.) failing to ensure a patient was observed in accordance with physician's orders for 1 (Patient #2) of 5 (Patient #1, #2, #3, #4, #5) sampled patients.

Findings:

1.) the toilets in the patients' bathrooms having a gap between the base of the toilet and the wall creating a ligature point and having toilet seats that could be raised, creating a ligature point at the hinge where there was an opening.

Observations were conducted on 07/20/2022 at 2:18 p.m. - 3:30 p.m. and on 07/21/2022 at 10:01 a.m. - 10:30 a.m. with S2DIR of the patients' bathrooms on all units. Further observation revealed 27 of 27 patients' bathroom toilets had a gap between the base of the toilet and the wall creating a ligature point and having toilet seats that could be raised, creating a ligature point at the hinge where there was an opening.

In an interview during the observations, S2DIR verified all 27 patients' bathroom toilets were of the same design and had access for potential ligature points.

2.) Failing to ensure a patient was observed in accordance with physician's orders for 1 (Patient #2) of 5 (Patient #1, #2, #3, #4, #5) sampled patients.

Review of Patient #2's medical record revealed an admit date of 07/01/2022 and a diagnosis of Schizoaffective Disorder, Bipolar type.

Review of Patient #2's Practitioner Order Sheet dated 07/10/2022 at 8:40 a.m. revealed, in part, an order for Q (every) 5 minute checks while awake. Precautions to renew: Sexually acting out, suicide, and self-harm.

Review of Patient #2's Patient Observation Record dated 07/10/2022 revealed, in part, Q (every) 15 minute checks were done while awake from 8:45 a.m. - 9:45 p.m. Review of Patient #2's Patient Observation Record dated 07/11/2022 revealed, in part, Q (every) 15 minute checks were done while awake from 7:15 a.m. - 9:00 a.m.

In an interview on 07/21/2022 at 4:15 p.m. S2DIR verified Patient #2 did not have Q (every) 5 minute checks while awake on 07/10/2022 from 8:45 a.m. to 9:45 p.m. and 07/11/2022 from 7:15 a.m. to 9:00 a.m.

Based on observation and interview, the hospital failed to ensure the condition of the physical plant and overall hospital environment was maintained in a manner that provided an acceptable level of safety and well-being for patients, staff, and visitors.

Findings:

Observations were conducted on 07/20/2022 at 2:18 p.m. - 3:30 p.m. and 07/21/2022 at 10:01 a.m. - 10:30 a.m. with S2DIR.

Room A was observed to have a hole in the wall below the window.

Room B was observed to have a hole in the wall on the right side of the window.

In an interview during the observation, S2DIR confirmed the above stated findings.

Based on observations and interview, the infection control officer failed to ensure the hospital's system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel was implemented. This deficient practice was evidenced by the hospital failing to maintain a sanitary environment.

Findings:

Observations were conducted on 07/20/2022 at 2:18 p.m. - 3:30 p.m. and 07/21/2022 at 10:01 a.m. - 10:30 a.m. with S2DIR.

Room C: the mattress on the patient bed was torn.

Room D: there was a dried red substance on the wall between the patient beds.

Room E: the mattress on the patient bed was torn.

Room F: the shower curtain in the bathroom had multiple black spots.

In an interview during the observation, S2DIR confirmed the above stated findings. S2DIR stated the dried red substance appeared to be blood on the wall.